Provider Demographics
NPI:1376637405
Name:WONG, BRUNSWICK ROYALTON (OD)
Entity Type:Individual
Prefix:DR
First Name:BRUNSWICK
Middle Name:ROYALTON
Last Name:WONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-4816
Mailing Address - Country:US
Mailing Address - Phone:662-332-7229
Mailing Address - Fax:662-378-3949
Practice Address - Street 1:411 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-4816
Practice Address - Country:US
Practice Address - Phone:662-332-7229
Practice Address - Fax:662-378-3949
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS452152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09539294Medicaid
MST21003Medicare UPIN